AMTSL

Active Management of the Third Stage of Labor for the prevention of Postpartum Hemorrhage

Prevention

PREVENTION

DIAGNOSTIC

TREATMENT

OVERVIEW

TECHNOLOGY Characteristics

Oxytocin diluted in a bag of IV fluid

Global Annual Deaths associated with obstetric hemorrhage

PERCENT (%)

NUMBER

Maternal

45%

115,000

Neonatal

N/A

N/A

Stillbirth

*

*

*Estimates under development

Condition

Active Management of the Third Stage of Labor (AMTSL) decreases the chance and intensity of postpartum hemorrhage (PPH). Postpartum hemorrhage is the loss of more than half a liter of blood during delivery, and it occurs in about 1 in 10 births accounting for about 100,000 maternal deaths per year. The third stage of labor is the time after the birth of the baby through the delivery of the placenta.

Mechanism of Action

Active management of the third stage of labor is composed of three steps: the administration of oxytocin or other uterotonics, cord traction to ease placental delivery, and uterine massage. The uterotonic helps the uterus contract which has the dual benefits of helping to deliver the placenta and slow the loss of blood. Similarly, cord traction in coordination with the natural contractions encourages a clean delivery of the placenta. Finally, the uterine massage both encourages clean delivery of the placenta while also helping to ensure against avulsion and uterine inversion.

Current Use in High-Resource Settings

Active management of the third stage of labor is included in the standard of care in high-resource settings. Hospital based deliveries will commonly use IV Oxytocin and often fluids as well to help manage the risk of hemorrhage. Furthermore, these facilities have the ability to use more invasive techniques such as balloon tamponade, various types of surgery and uterine artery embolization to control hemorrhage if AMSTL fails.

Current use in low-Resource Settings

Correct use of AMTSL has been observed in about 1 in ten cases in public hospitals in Nicaragua and about 60% of cases in Benin as well as a variety of rates in between in a study of seven low income countries. AMTSL is also uncommon among home birth attendants, though the practices are encouraged by the WHO. However, this practice requires training for the proper use of uterotonics, cord traction and massage.

REPRESENTATIVE DEVICES

MAKE

Dose

PRICE

TECH

STATUS

NOTES

Oxytocin/Uniject

10 IU

$0.80-$1.00

Limited

Undergoing market expansion

Oxytocin

10 IU

$0.15-$0.25

Marketed

Widely used, requires refrigeration

Ergometrine

1mg

$0.35-$0.60

Marketed

Requires refrigeration

Synometrine

5IU + 0.5mg

$0.45-$0.70

Marketed

Oxytocin + ergometrine

Misoprostol

600 mcg

$0.42-$3.60

Marketed

Potentially self-administrated

*Prices are approximated. Actual pricing can and will vary with market conditions.

CHARACTERISTICS OF REPRESENTATIVE PRODUCT

TECHNOLOGY CHARACTERISTICS

OPERATIONAL PARAMETERS

POTENTIAL OPPORTUNITIES FOR IMPROVEMENT

SKILLS

REQUIRED

Intended end user

Training required

Time required per use

Skilled birth attendant

Course to become a skilled birth attendant which includes training in AMTSL

N/A

ENVIRONMENT/ INFRASTRUCTURE

Power required

Waste collection

Complementary technologies required

Temperature and storage

Maintenance

None

Heat stable product

N/A

The primary technology associated with AMTSL is uterotonics.

COST

Cost to train (approximate)

Cost/course (approximate)

$20-$200 per person

Cost to train is an estimate of the marginal cost to add AMTSL to a skilled birth attendant training.
Cost/course is primarily the cost of the uterotonic.

OTHER

Portability

Regulatory

Efficacy

<200g (weight of drug with packaging)

Uterotonics and skilled birth attendants regulated differently in different countries

Can reduce the risk of postpartum hemorrhage by 62%

Sources:
US Department of Health and Human Services, "Active Management of the third stage of labor: prevention and treatment of postpartum hemorrhage"http://guideline.gov/content.aspx?id=15263. WHO: "Use of active management of the third stage of labor in seven developing countries" http://www.who.int/bulletin/volumes/87/3/08-052597/en/index.html